Evidence-Based Review and Discussion Points

Important Outcomes for Parents of Critically Ill Children.

Introduction: communication is considered the main tool in the work of the members of the Primary Health Care (PHC) team with patients, with the community, with political and managerial levels, between levels of care and the members of the equipment. Objective: to describe communication strategies and their impact on the performance of members of the Primary Health Care Team. Method: observational, descriptive, cross-sectional study in the 18 health centers of Sanitary Zone No. 4. Municipality of Córdoba in 2020. 74 members of the health centers were studied. The questions were tabulated according to the Likert scale for terms according and frequency. Results: the average age was 42.74 ± 9.41 years, the female sex prevailed in 58,6 % and 48,5 % are professional and licensed nurses. The average work seniority was 13.02 ± 7.51 years. Communication strategies do not perceive nursing as a manager with 37 negative responses 2.75 ± 0.43. Regarding the communication plan, 54,28 % do not positively perceive participating in the management of health networks 2.23 ± 0.71. The strategies for nursing management in the communication plan are not related (rho=0.0391, P=0.7480). Conclusions: there is a good perception of communication strategies except for the nurse as manager. The communication plan shows to be related to communication strategies except for nursing management

Disruption of Patient and Family Centered Care Through the COVID-19 Pandemic

Comparison of severity and diagnosis-adjusted mortality rates from pediatric intensive care units (ICUs) staffed by physicians training in pediatric critical care, as well as pediatric residents, with mortality rates from pediatric ICUs staffed with only pediatric residents. Cohort study. Sixteen volunteer pediatric ICUs, eight with critical care fellowships, and eight without such programs. Consecutive admissions until at least 14 deaths occurred at each site. None. Descriptive data and Pediatric Risk of Mortality scores were collected. Severity and diagnosis-adjusted mortality risk for each patient was computed by a predictor developed in an independent sample. The effect of fellowship programs was analyzed at the institution level by ranking the pediatric ICUs in terms of observed/predicted mortality rates, and, at the patient level, by including a training factor into the predictor model. The use of monitoring and therapeutic modalities was compared in the two types of pediatric ICUs by severity-adjusted odds ratios. There were 2,744 admissions (145 deaths) to the eight fellowship pediatric ICUs and 3,006 admissions (150 deaths) to the eight nonfellowship pediatric ICUs. Institutional characteristics were not different between the two pediatric ICU sets. The raw mortality rates were similar (fellowship 5.28%; nonfellowship 4.99%, p = .714). Institution-level analyses indicated that fellowship pediatric ICUs performed better than nonfellowship pediatric ICUs; fellowship pediatric ICUs ranked better than pediatric ICUs without such programs (Wilcoxon rank-sum test, p = .020). However, both the best and the worst ranked pediatric ICUs had fellowships. Patient-level analyses also indicated that outcome was significantly influenced by the fellowship status of the pediatric ICU. Using two different patient-level analytic approaches, the odds of dying in a fellowship pediatric ICU vs. a nonfellowship pediatric ICU were 0.592 (95% confidence interval 0.468 to 0.749, p = .0001) and 0.714 (95% confidence interval 0.529 to 0.964, p = .028). Pediatric ICUs with fellowship programs performed more (p < .05) invasive monitoring, including intra-arterial catheters and central venous pressure catheters, and more technological therapies such as mechanical ventilation. Pediatric ICUs with critical care fellowship programs are generally associated with better risk-adjusted mortality rates than pediatric ICUs without such fellowship training programs. The cause for this effect requires a more in-depth study. The presence or absence of such training programs does not guarantee superior or inferior performance.

Providing more opportunities for first-year medical students to interact with patients in clinical settings is a current discussion topic in medical student education reform. Early clinical experience helps students bridge the gap between textbook and patient while observing patient-centered care, and serves as a first step for students to develop the skills needed to work cooperatively as members of a multidisciplinary health care team. The author developed a model to provide perinatal education to first-year medical students, consistent with the concept of interprofessional education. Primarily first-year medical students participated in the nurse-developed education model, a component of a noncredit extracurricular, student-run perinatal program at a Midwestern university medical center. Students were placed at the bedsides of hospitalized women to provide support and education to them during perinatal procedures, labor, childbirth, and cesarean delivery. A total of 350 students participated over a period of 13 school calendar years. Students remarked that participation in the program reinforced the importance of their concurrent anatomy and physiology classes. They observed interdependence and cooperation among the members of the health care team caring for women, and their evaluations of their experiences at the bedside were highly positive. Women consistently expressed appreciation for the additional individualized attention and education received from our student and nurse team. Nurses can enhance the learning of first-year medical students in the maternity care clinical setting. This nurse-developed education program provided students with a variety of vivid clinical experiences with maternity patients.

Successful Integration of Advanced Practice Providers Into a Pediatric Academic Community Intensive Care Unit

Provider status effort engaged on Capitol Hill

Background: Social workers (SWs) and chaplains are trained to support families facing challenges associated with critical illness and potential end-of-life issues. Little is known about how parents view SW/chaplain involvement in care for critically ill children with cancer. Methods: We studied parent perceptions of SW/chaplain involvement in care for pediatric intensive care unit (PICU) patients with cancer or who had a hematopoietic cell transplant. English- and Spanish-speaking parents completed surveys within 7 days of PICU admission and at discharge. Some parents participated in an optional interview. Results: Twenty-four parents of 18 patients completed both surveys, and six parents were interviewed. Of the survey respondents, 66.7% and 75% interacted with SWs or chaplains, respectively. Most parents described SW/chaplain interactions as helpful (81.3% and 72.2%, respectively), but few reported their help with decision making (18.8% and 12.4%, respectively). Parents described SW/chaplain roles related to emotional, spiritual, instrumental, and holistic support. Few parents expressed awareness about SW/chaplain interactions with other healthcare team members. Conclusions: Future work is needed to determine SWs’/chaplains’ contributions to and impact on parental decision making, improve parent awareness about SW/chaplain roles and engagement with the healthcare team, and understand why some PICU parents do not interact with SWs/chaplains.

Stakeholder-developed interventions are needed to support pediatric intensive care unit (PICU) communication and decision-making. Few publications delineate methods and outcomes of stakeholder engagement in research. We describe the process and impact of stakeholder engagement on developing a PICU communication and decision-making support intervention. We also describe the resultant intervention. Stakeholders included parents of PICU patients, healthcare team members (HTMs), and research experts. Through a year-long iterative process, we involved 96 stakeholders in 25 meetings and 26 focus groups or interviews. Stakeholders adapted an adult navigator model by identifying core intervention elements and then determining how to operationalize those core elements in pediatrics. The stakeholder input led to PICU-specific refinements, such as supporting transitions after PICU discharge and including ancillary tools. The resultant intervention includes navigator involvement with parents and HTMs and navigator-guided use of ancillary tools. Subsequent research will test the feasibility and efficacy of our intervention.

BackgroundRespectful, equitable, and supportive health care team interactions with patients and their companions are a key part of quality health care services. Despite the importance of communication and other aspects of engagement during inpatient postpartum care, little is known about how care is experienced during this period from families’ perspectives.MethodsThis study collected video and audio data with 15 birthing families (n = 9 English-speaking and n = 6 Spanish-speaking) and their health care team members during inpatient postpartum care in a southeastern United States academic medical center. This analysis quantifies health care team member presence in family hospital rooms, assesses linguistic appropriateness of health care team member verbal communication, and describes birthing parent and companion verbal reactions to health care team member interactions. A behavioral taxonomy was applied to identify these codes in the 12 h prior to hospital discharge. Additionally, we transcribed the birthing parent and companion verbal reactions for 10-minutes each time the health care team member departed their room. This content was inductively coded to identify topics and develop themes.ResultsA total of 160 h of video and audio data were coded across 15 participating families for this analysis. There were 19.9 h of missing data in the 12 h prior to hospital discharge due to equipment being turned off across five participants. At least one health care team member was present in the postnatal unit rooms within the observation period in 200 instances (median 13 times, range 5 to 19 times per participating family). Communication with Spanish-speaking birthing parents was linguistically appropriate for between 20.0% and 75.0% of interactions. Following health care team member presence, birthing parent and companion reactions were indeterminate 1 time, no verbal reaction 107 times, positive 25 times, confused 38 times, and negative 52 times. Many parents expressed more than one reaction. Reaction topics included clarity of information provided, postpartum pain management, hospital discharge coordination, health care team member conduct, and access to supplies.ConclusionThere are strengths in postpartum patient engagement as well as areas for health care team improvement. More appropriate communication including setting of clearer expectations surrounding various aspects of services on the postnatal unit may improve patient experiences. As a part of this improved quality of inpatient postpartum care, consistent utilization of interpretation services could decrease patient confusion, enable shared decision-making, and promote positive patient-provider relationships.

Are you ready for health care teams?

Fuhrman and Zimmerman’s Pediatric Critical Care, 6th Edition

Clinical learning contexts influence how medical students engage with entrustment decisions. However, it is unclear how students and health care team members perceive the entrustment decision process. This study explored which factors students and team members consider relevant to entrustment decisions in early clinical rotations. The authors conducted a case study at an academic teaching hospital, interviewing 28 medical students and four health care team members during the clerkship year. Within a social constructivist epistemology, we explored students' and health care team members' perceptions of ad hoc entrustment decisions using semi-structured interviews. Transcripts from the interviews and notes from feedback rounds with students were used for analysis. Medical students in their core clerkship year perceived clinical residents as critical educational gatekeepers and key facilitators of entrustment decisions. Another important theme emerged around students' motivation, initiative and willingness to engage with the health care team and patients. Students actively engaged in trust formation processes with different health care team members. The entrustment decision process was perceived as multilateral and dynamic, involving all health care team members and patients. Multiple entrusting supervisors for clerkship students, including nurses and psychologists, emerged from our interview data. They assumed an active role in negotiating entrustment decisions both with and for clerkship students, either facilitating or hindering opportunities. The entrustment decisions emerged as a result of a multifaceted supervisor network interaction. Supervising residents' ability to integrate students into clinical teams seems to be a critical factor in facilitating entrustment opportunities for clinical activities. Students' active management of informal supervisor networks of health care team members and these team members' willingness to assume responsibility for the students' education emerged as relevant aspects for ad hoc entrustment. Our data suggest that supervision from different health professionals is beneficial for clinical education of medical students and merits further exploration.

The purpose of the current study was to characterize the experiences of cancer patients and their caregiver/family members around their relationship with their oncologist, health care team, and the hospital environment. Participants were recruited from The Ohio State University Comprehensive CancerCenter. Participant sociodemographic factors were assessed. Focus groups were moderated and recordedby two members of the research team using a semi-structured interview format. The audio recordings were transcribed and uploaded to NViVO 11 for analyses. Four focus groups were conducted with 25 participants. The mean age of participants was 58.4years (SD = 15.1, range 26.0-76.0). Participants who were identified as patients (84%) reported different malignancy types including breast (56%), gynecologic (16%), skin (6%) oral (6%), and non-Hodgkin's lymphoma (6%). Three major themes that emerged around the patient-oncologist relationship, include (1) choosing a physician and health care location, (2) relationship with the physician, health care team, and hospital environment; and (3) patient engagement and decision-making. Subthemes highlighted the importance of the flexible communication behaviors and trustworthiness of the oncologist, and the impact of other health care team members. Patients also reported the desire to be engaged in making treatment-related decisions and to include the caregiver/spouse in all stages of cancer care. Understanding the experience of cancer patients in a relationship with their oncologist in the context of the health care team and health care environment will be an important area of future research to provide optimal, tailored patient-centered cancer care.

Background: Community pharmacists could play more potential role when finding ways to allocate effectively limited healthcare resources in primary care in many developing countries, including India. Pharmacists could participate in national public health programs, and cooperate effectively with other members of health care team. This small-scale pilot study was designed to develop a method for characterizing physicians' perceptions on the role of pharmacists in public health and patient care in India. Methods: Six volunteers visited 800 physicians in Southern region in India and collected data in 2014. The survey tool consisted of 28 structured questions concerning: (i) physicians' experiences of cooperation with pharmacists; (ii) physicians' general opinion on pharmacists' involvement in National Public Health Programs (NPHPs) in India; and (iii) pharmacists' involvement in 11 major NPHPs. The data were collated and extracted and descriptive statistical analysis was conducted by SAS (version 9.3). Results: Of total 800 physicians contacted, 129 responded. Of the responding physicians 98% were comfortable with pharmacists' roles in general, 96% were comfortable or somewhat comfortable to collaborate with pharmacists, and 82% regarded pharmacists as part of health care team. The physicians with shorter professional practice were more positive on pharmacists' involvement in NPHPs than physicians having at least 11 years' experience. Overall response of accepting pharmacists' role and involvement in NPHPs was positive, Pulse Polio, HIV/AIDS, Tuberculosis and Tobacco control, and Leprosy eradication programs being the top NPHPs where physicians perceived pharmacists had a role to play. Conclusion: This small-scale pilot study indicates that Indian physicians are willing to collaborate with pharmacists and are comfortable to involve them in the health care team. The survey also revealed differences in opinions between junior and senior physicians: the longer physicians' practice experience was, the less favorable they were for pharmacists' involvement in NPHPs.